CSAO

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CSAO Theta ChapterEducation DayMay 30,
2009
Infection Control Facts How to Select an Ideal
Disinfectant
Lee Nesbitt, BMSc Manager, Professional
Technical Services Virox Technologies Inc Phone
1-800-387-7578 x115 Email lnesbitt_at_virox.com
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Outbreaks in the News
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Legal Issues in Patient Safety

• 2003 CDN Hospitals notified gt900 patients that
  improper sterilization of equipment may have
  exposed them to HIV, Hepatitis and other
  diseases. 150M class action lawsuit filed
  alleging negligence in failing to meet adequate
  sterilization standards.
• Government ordered a province-wide audit of
  hospital infection-control practices
• Healthcare Quarterly Vol. 8, Special Issue
• October 2005

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Patient Disclosure

• Canadian law clearly establishes a positive duty
  on care providers to inform patients of errors
  that occur during their care
• When care providers realize that patients may
  have been exposed to infection from equipment,
  other patients or healthcare workers, a legal
  obligation may arise to contact patients to warn
  them of the risk and provide advice regarding
  appropriate follow-up testing and care.

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On the Same Page

• Terminology, Definitions,
• Common Words

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Cleaning

• The removal of adherent visible soil, blood,
  protein substances (tissue) and other debris from
  surfaces by mechanical or manual process
• Generally accomplished with water and detergents
• Removes or eliminates the reservoirs of potential
  pathogenic organisms

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Major Groups Of Microbes
Most Susceptible

• Viruses (enveloped)
• Bacteria (Gram ve Gram -ve)
• Fungi
• Viruses (non-enveloped)
• Mycobacteria
• Protozoa
• Bacterial Spores

Least Susceptible
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Process for Choosing a Disinfectant
Consider the Device Classification (According to
Spaulding)
Once the device has been defined determine the
Disinfection Process
Choose the CORRECT Product
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Process for Choosing a Disinfectant
Sterilization
Critical Devices
High Level Disinfection
Semi-Critical Devices
Intermediate Level Disinfection
Non-Critical Devices
Low Level Disinfection
Foot Care Instruments defined as critical
according to CCDR Vol. 23S8 (Dec 1997) Infection
Control Guidelines Foot Care by Health Care
Providers
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Definition Low Level Disinfectant

• refers to the level of disinfection required when
  processing noncritical items or some
  environmental surfaces and kills most vegetative
  bacteria and some fungi as well as enveloped
  viruses but not mycobacteria or bacterial spores.

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Definition Intermediate Level Disinfectant

• refers to disinfectant that kills vegetative
  bacteria, most viruses and most fungi but not
  resistant bacterial spores.

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Definition High Level Disinfectant

• refers to a process which destroys vegetative
  bacteria, mycobacteria, fungi, enveloped and
  non-enveloped viruses, but not necessarily
  bacterial spores

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Definition Chemosterilization

• refers to the chemical disinfection process that
  destroys all forms of microbial life including
  bacteria, viruses, spores and fungi.

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Microbial Kill Summary
LLD ILD HLD Chemical Sterilants
Enveloped Viruses 3 Log / 99.9 3 Log / 99.9
Vegetative Bacteria 6 Log / 99.9999 6 Log / 99.9999
Fungi 5 Log / 99.999 5 Log / 99.999 5 Log / 99.999 5 Log / 99.999
Non-Enveloped Viruses 3 Log / 99.9 3 Log / 99.9
Mycobacteria 4 Log / 99.99 6 Log / 99.9999 6 Log / 99.9999
Spores 6 Log / 99.9999 6 Log / 99.9999
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DisinfectantsDesired Traits Limiting Factors
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Basic Facts

• Disinfectants are the backbone of Environmental
  Infection Control
• gt8000 Products registered in the U.S. Canada
• 50 of which are used for Healthcare Infection
  Control
• There are 300 different active chemistries
• 14 are in 95 of the disinfectant products
• 6 are the most common

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Microbiological

• Detergency properties for cleaning
• Not Readily Neutralized in Organic or Inorganic
  Matter
• Microorganism Resistance will not develop
• Broad-Spectrum Fast Acting Germicidal Activity

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Chemistry Comparisons - Surfaces
Alcohols Chlorine Phenolics QUATs AHP
Must have good cleaning ability to remove organic soil load on surface. Alcohols are not effective cleaners as they do not contain detergency Properties Chlorine can be inactivated by a soil load and do not contain detergency Properties Phenolics are ineffective cleaners Quaternary Ammonia Compounds are not effective cleaners AHP contains a combination of superior surfactants that are proven effective cleaners in synergy with H2O2
Is effective in a soil load. Testing is done with no soil load. Neutralized by soil. Testing is done with a soil load Testing is generally done without a soil load. Testing is done with a soil load.
Will not lead to development of resistant organisms Active ingredient evaporates Active ingredient evaporates Leaves active ingredient residual on surface Leaves active ingredient residual on surface Active ingredient hydrogen peroxide evaporates from surface
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Chemistry Comparisons - Surfaces
Alcohols Chlorine Phenolics QUATs AHP
Vegetative Bacteria YES 3 min to 10 min YES 10 min YES 5 min to 10 min YES 3min to 10 min YES 30 sec to 20 min
Enveloped Viruses YES 3 min to 10 min YES 10 min YES 3 min to 10 min YES 3 min to 10 min YES 1 min to 5 min
Fungi YES 3 min to 10 min YES 10 min YES 3 min to 10 min YES 3 min to 10 min YES 3 min to 5 min
Non-Enveloped Viruses NO YES 10 min YES / NO Product Specific Review label 3 min to 10 min NO YES 1 min to 5 min
Mycobacteria YES 3 min to 10 min YES 10 min YES 3 min to 10 min ONLY WITH SOLVENT OR ALCOHOL 3 min 10 min YES 1 min to 5 min
Bacterial Spores NO YES 10 min NO NO YES 10 min
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Chemistry Comparisons - Instruments
OPA Gluteraldehyde AHP
Fungi YES 10 min YES 20 min 45 min YES 5 min 20 min
Mycobacteria YES 10 min YES 20 min 45 min YES 5 min 20 min
Bacterial Spores YES 32 hours YES 8 12 hours YES 20 min 6 hours
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Chemical

• Safe to Transport Easy to Store
• Improper storage of disinfectants may lead to
  explosions or fires
• Long Shelf Life
• Improper or prolonged storage of disinfectants
  may lead to growth of bacteria in them
• Non-Corrosive Material Compatible
• Using the wrong type or level of disinfectant may
  cause corrosion or other damage to expensive
  items such as flexible endoscopes

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Chemical Profile - Surfaces
Alcohols Chlorine Phenolics QUATs AHP
Does not have storage limitations Flammable Highly reactive with other chemicals creating toxic by-products Toxicity poses risk for water and food contamination. Cannot be used around children Caution with products that contain solvents or alcohols Non-flammable or combustible
Realistic Shelf life and stabilty Readily evaporates decreasing concentration Readily degrades once open, diluted product must be made fresh daily Relatively stable in both concentration and Use Dilution Relatively stable in both concentration and Use Dilution Stable in concentrate and Use Dilution
Compatible with a wide variety of surfaces and materials Concerns with plastics and glues Concerns with stainless steel and fabric materials Concerns with residue build up on vinyl Concerns with residue build up or Quat burn on some flooring and vinyl Concerns with prolonged exposure to copper and brass
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Chemical Profile - Instruments
OPA Gluteraldehyde AHP
Does not have storage limitations Non-flammable or combustible Do not store at elevated temperatures and keep away from ignition sources. Non-flammable or combustible
Realistic Shelf life and stability Shelf life decreases to 75 days once bottle is opened Once activated shelf life rapidly decreases Shelf life does not decrease once opened
Compatible with a wide variety of surfaces and materials Concerns with plastics and glues Concerns with residue build up on vinyl Concerns with prolonged exposure to copper and brass
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Toxicity

• Non-Toxic to humans animals
• Non-Allergenic non-sensitizing
• Non-Hormone disruption
• Certain microbicidal chemicals or their breakdown
  products can disrupt hormone function in humans
  animals
• Safe for the User and Patient
• Exposure to cleaner disinfectant vapours may
  cause respiratory sensitization
• Improperly rinsed endoscopes or other devices may
  release residues of disinfectants into body
  cavity

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Health Safety - Surfaces
Alcohols Chlorine Phenolics QUATs AHP
Indoor Air Quality (VOCs) Contains high levels of VOCs which contribute to poor indoor air quality Creates high levels of VOCs through reactions with surface and soil load Contain VOCs Toxicity poses risk for water and food contamination Contain VOCs Contains no VOCs
Does not contain hormone disrupting or carcinogenic chemicals Does not contain APEs / NPEs Highly reactive creating toxic / carcinogenic by-products Phenolic Compounds have been found to be carcinogenic Many formulations contain APEs / NPEs Does not contain APEs/NPEs is not carcinogenic
Will not lead to development of resistant organisms Active ingredient evaporates Active ingredient evaporates Leaves active ingredient residual on surface Leaves active ingredient residual on surface Active ingredient hydrogen peroxide evaporates from surface
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Health Safety - Instruments
OPA Gluteraldehyde AHP
Indoor Air Quality (VOCs) Contains high levels of VOCs which contribute to poor indoor air quality Contain VOCs Requires special ventilation Contains no VOCs
Adverse Reactions to Residues left on surfaces after reprocessing Residues have lead to anaphylactic reactions Anaphylactic reactions to both vapours and residues No Active Residue left on surface
Will not lead to development of resistant organisms Leaves active ingredient residual on surface Leaves active ingredient residual on surface Active ingredient hydrogen peroxide evaporates from surface
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Environmental

• Environmentally sound (Biodegradable)
• Environmentally-stable sanitizers disinfectants
  can contaminate food or water (groundwater
  surface water)
• No Active Residual Chemistry
• Good Air Quality
• Free of any pungent smell
• No Volatile Organic Compounds (VOCs)
• Use of gaseous or volatile products may
  negatively affect indoor air quality
• Fragrance Free

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Environmental Sustainability - Surfaces
Alcohols Chlorine Phenolics QUATs AHP
Positive environmental profile including indoor air quality. Contains high levels of VOCs which contribute to poor indoor air quality Creates high levels of VOCs through reactions with surface and soil load Contain VOCs Toxicity poses risk for water and food contamination Contain VOCs often contain hormone disruptors Contains no VOCs and no hormone disruptors
Will not lead to development of resistant organisms Active ingredient evaporates Active ingredient evaporates Leaves active ingredient residual on surface Leaves active ingredient residual on surface Active ingredient hydrogen peroxide evaporates from surface
Carries EcoLogo or Green Seal Certification Does not meet certification criteria Does not meet certification criteria Does not meet certification criteria Only1 product meets Canadas EcoLogo criteria Received certifications by EcoLogo and Green Seal
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Environmental Sustainability - Instruments
OPA Gluteraldehyde AHP
Positive environmental profile including indoor air quality. Contains high levels of VOCs which contribute to poor indoor air quality Contain VOCs requires special ventilation Contains no VOCs does not require special ventilation
Restrictions to Disposal Restrictions in disposal Restrictions in disposal Can be disposed into municipal waste water
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Understanding the Label
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TPD Disinfectant Drugs

• Clearly outlines the requirements of what must be
  included on a label
• Name of Product Manufacturer
• DIN must be on the main panel
• Active Ingredients
• Intended Use
• Net contents
• Lot Number Expiry Date
• Precautionary symbols and cautionary statements

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TPD Disinfectant Drugs

• Label requirements continued
• Claims
• Area or Site of Use
• Directions for Use
• Specific directions for preparing in-use dilution
  including ratios or metric units
• Reference to level of hardness of product diluent
  at time of testing
• Pre-cleaning or cleaning requirements
• Contact Times
• Temperature
• Stability of diluted or in-use product

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TPD Disinfectant Drugs

• Label requirements continued
• Rinse procedures
• Directions for Use for intended use against
  bloodborne pathogens
• Reference to PPE
• Directions for disposal of infectious waste

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Conclusions
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Disinfectant Selection

• Remember
• Match Product with Protocol
• Surfaces vs Instruments
• Cleaning 1st step
• Disinfection 2nd step
• Contact Time is MANDATORY!

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Virox Technologies Inc.

• Engineering Revolutionary Disinfectants for the
  War Against Microbes

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References

• Infection Control Guidelines Hand Washing,
  Cleaning, Disinfection and Sterilization in
  Health Care, Health Canada. Dec 1998, Vol 24S8
• Routine Practices and Additional Precautions for
  Preventing the Transmission of Infection in
  Health Care, Health Canada. July 1999, Vol 25S4
• Guidelines for Environmental Infection Control in
  Healthcare Facilities, CDC. MMWR June 2003, Vol
  52, No RR-10
• Best Practices for Cleaning, Disinfection and
  Sterilization in All Health Care Settings, PIDAC,
  May 2006

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References

• Block S. Disinfection. Sterilization, and
  Preservation, 5th Ed. 2001
• Mayhall CG. Hospital Epidemiology and Infection
  Control, 3rd Ed. Philadelphia. Lippincott
  Williams Wilkins, 20041473-1522
• Cokendolpher JC Haukos JF. The Practical
  Applications of Disinfection and Sterilization in
  Health Care Facilities, Chicago. American
  Hospital Association, 1996 47-59
• Rutala WA. APIC Guideline for Selection and Use
  of Disinfectants AJIC 199017(2) 99-117

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References

• Bessems E. The effect of practical conditions on
  the efficacy of disinfectants. Int Biodeter
  Biodeg 1998177-183
• Crawford L et al. A Comparison of Commonly Used
  Surface Disinfectants Alcohol-, Phenol-,
  Chlorine- and Quat Disinfectants.
  www.infectioncontroltoday.com/articles/0b1feat2.ht
  ml
• Russel AD. Glutaraldehyde Current Status and
  Uses. Inf Con Hosp Epi 199415 (11) 724-733
• Rutala WA. Sporicidal Activity of Chemical
  Sterilants Used in Hospitals. Inf Con Hosp Epi
  1993 14(12) 713-718

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References

• Rutala WA Weber DJ. The benefits of surface
  disinfection. AJIC 200432(4) 226-229
• Woldkoff P et al. Risk in cleaning chemical and
  physical exposure. Sci of Total Env
  1995215135-156
• Sattar SA. Current issues in testing, selection
  and use of microbicides in infection control a
  critical review. AICJ 20049(3)84-100
• Health Canada. Therapeutic Products Programme
  Guidelines Disinfectant Drugs. Fall 1999

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References

• Degussa, Hydrogen Peroxide Properties, Handling
  and Application
• Hugo, Inhibition and destruction of the microbial
  cell
• Ascenzi, Handbook of disinfectants and
  antiseptics
• CCDR Supplement, Vol 23S8 (Dec 1997), Infection
  Control Guidelines Foot Care by Health Care
  Providers. http//www.phac-aspc.gc.ca/publicat/ccd
  r-rmtc/97vol23/23s8/fcindexe.html